Part 15.
TEXAS HEALTH AND HUMAN SERVICES COMMISSION
Chapter 354.
MEDICAID HEALTH SERVICES
Subchapter A. PURCHASED HEALTH SERVICES
9.
AMBULANCE SERVICES
1 TAC §354.1113
The Texas Health and Human Services Commission (HHSC) proposes
to amend §354.1113, concerning charges for ambulance services.
This rule is being amended to comply with the federal Health Insurance
Portability and Accountability Act (HIPAA) of 1996. HIPAA requires that ambulance
services be reimbursed both base rates and mileage rates. Currently, ground
ambulance services are reimbursed by either a flat rate or a base rate plus
a mileage rate. The current flat rate is a total charge for service, regardless
of mileage. In order to conform to the federal requirement, HHSC is deleting
the "flat" rate option and replacing it with "a base" rate, to which the mileage
rate may be added.
The revisions also update internal references to other sections of the
Texas Administrative Code and replace references to the Texas Department of
Health and to department with references to Health and Human Services Commission
(HHSC) or its designee, where appropriate.
Tom Suehs, Deputy Commissioner for Financial Services, has determined that
during the first five years the amended rule is in effect, there will be fiscal
implications to state government as a result of enforcing or administering
this rule. There will be no fiscal implications for local governments.
The effect on state government for the first five-year period the proposed
section will be in effect is an estimated additional cost of $4,502 for fiscal
year (FY) 2004, $4,839 for FY 2005, $4,984 for FY 2006, $5,134 for FY 2007,
and $5,288 for FY 2008.
Mr. Suehs also has determined that during the first five years the proposed
amendment is in effect, the anticipated public benefit is the state's compliance
with federal requirements. There are no anticipated economic costs to persons
required to comply with the proposed rule, nor any impact on local employment.
There is no anticipated impact on small businesses and micro-businesses to
comply with the section as proposed as they will not be required to alter
their business practices as a result of the section.
HHSC has determined that this proposed rule does not restrict or limit
an owner's right to their property that would otherwise exist in the absence
of governmental action and therefore does not constitute a taking under §2007.043,
Government Code.
Written comments on the proposed rule may be submitted to Cynthia Walker,
Program Specialist, Medicaid/CHIP Benefits, HHSC, 1100 W. 49th, Austin, Texas
78756, within 30 days of publication of this proposal in the
Texas Register
.
A public hearing is scheduled for June 17, 2003, from 2:30 p.m. to 4:30
p.m. The hearing will be held in the Palo Duro Conference Room, 12555 Riata
Vista Circle, Bldg. 3, Austin, Texas 78727.
The amendment is proposed under the Texas Government Code, §531.033,
which provides the Commissioner of HHSC with broad rulemaking authority; and
under the Human Resources Code, §32.021 and the Texas Government Code, §531.021(a),
which provide HHSC with the authority to administer the federal medical assistance
(Medicaid) program in Texas.
The proposed amendment affects the Texas Government Code, Chapter 531,
and Chapter 32 of the Human Resources Code. No other statutes, articles, or
codes are affected by the proposed rule.
§354.1113.Additional Claim Information Requirements.
In addition to the general requirements in
§354.1001
[
(1)
type of ambulance service provided (air, ground, or boat);
(2)
origin and destination of each separate trip;
(3)
charges for ambulance services,
including both base
rates and mileage rates, and written justification of the number of miles
traveled
[
(4)
appropriate supporting documentation requested by the
Texas Health and Human Services Commission
[
This agency hereby certifies that the proposal has been
reviewed by legal counsel and found to be within the agency's legal authority
to adopt.
Filed with the Office of
the Secretary of State on May 12, 2003.
TRD-200302948
Steve Aragon
General Counsel
Texas Health and Human Services Commission
Earliest possible date of adoption: June 22, 2003
For further information, please call: (512) 424-6576
4.
LIMITATIONS
1 TAC §354.1875
The Health and Human Services Commission ("commission") proposes
an amendment to §354.1875, relating to Limitations on Provider Charges
to Recipients. The proposed amendment repeals current subsections (b) and
(d). Subsection (b) authorizes the commission to reduce the amount of reimbursement
paid to a pharmacy provider enrolled in the Medicaid Vendor Drug Program by
any cost sharing amount required of a Medicaid recipient pursuant to §354.3200
of this title, relating to Cost Sharing for Medicaid Recipients. Subsection
(d) confirms a Medicaid recipient's responsibility for cost sharing amounts
in accordance with federal regulations that authorize and limit recipient
cost sharing.
Subsections (b) and (d) were added to §354.1875 in late 2002, simultaneously
with the adoption of §354.3200 and an amendment to §355.8551, relating
to the Medicaid Vendor Drug Program Dispensing Fee. Both subsections are proposed
for repeal with §354.3200 and complementary provisions in §355.8551.
The changes made by these rules were enjoined by a state district court in
Travis County on December 16, 2002, the first business day following the effective
date of the rules. The commission, therefore, has not implemented the cost
sharing established under §354.3200 or generated the program cost savings
that were anticipated from the successful implementation of the section. The
Texas Legislature also is currently considering legislation that would codify
certain Medicaid cost sharing requirements. The repeal of subsections (b)
and (d) and §354.3200 is proposed in order to accommodate new public
policy as prescribed by the 78th Texas Legislature and to enable the commission
to consider all potential cost savings initiatives.
Tom Suehs, Deputy Commissioner for Financial Services, has determined that
for the first five years the proposal is in effect, there will be no fiscal
implications for the state or local governments as a result of enforcing or
administering the amended rule. Because the reimbursement adjustments authorized
by subsection (b) were never implemented, the state has not realized the cost
savings anticipated for that subsection. Also, since §354.3200 is proposed
for repeal, it is not necessary to refer to federal regulations concerning
Medicaid recipient cost sharing obligations as provided in subsection (d).
Mr. Suehs also has determined that during the first five years the proposal
is in effect, no change in public benefit is anticipated as a result of enforcing
the amended rule. As the proposed amendment conforms the language of the rule
to policy currently in effect, there is no anticipated impact on small businesses
and micro-businesses to comply with the amended rule as proposed, as they
will not be required to modify business practices. For the same reasons, there
are no anticipated economic costs to persons who are required to comply with
the proposed rule. There is no anticipated impact on local employment.
HHSC has determined that the proposed rule is not a "major environmental
rule" as defined by §2001.0225 of the Texas Government Code. "Major environmental
rule" is defined to mean a rule the specific intent of which is to protect
the environment or reduce risk to human health from environmental exposure
and that may adversely affect in a material way the economy, a sector of the
economy, productivity, competition, jobs, the environment or the public health
and safety of a state or a sector of the state. The proposed rule is not specifically
intended to protect the environment or reduce risks to human health from environmental
exposure.
HHSC has determined that this proposed rule does not restrict or limit
an owner's right to his or her property that would otherwise exist in the
absence of governmental action and therefore does not constitute a taking
under §2007.043, Government Code.
Written comments on the proposal may be submitted to Ms. Dee Sportsman,
Medicaid/CHIP Benefits, Texas Health and Human Services Commission, 1100 West
49th Street, Austin, Texas 78756, within 30 days of publication of this proposal
in the
Texas Register
.
The rule is proposed under the Texas Government Code, §531.033,
which provides the Commissioner of HHSC with broad rulemaking authority; Human
Resources Code, §32.021, and the Texas Government Code, §531.021(a),
which provide HHSC with the authority to administer the federal medical assistance
program (Medicaid) in Texas; and the Texas Government Code, §531.021(b),
which provides HHSC with the authority to propose and adopt rules governing
the determination of Medicaid reimbursement rates, fees, and charges.
No other statutes, articles, or codes are affected by the proposal.
§354.1875.Limitations on Provider Charges to Recipients.
(a)
A provider of Medicaid vendor drug services agrees to accept
the vendor payment as payment in full for pharmaceutical services provided
each recipient.
(b)
[
[
[
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed with the Office of
the Secretary of State on May 12, 2003.
TRD-200302958
Steve Aragon
General Counsel
Texas Health and Human Services Commission
Earliest possible date of adoption: June 22, 2003
For further information, please call: (512) 424-6576
1 TAC §354.3200
(Editor's note: The text of the following section proposed for
repeal will not be published. The section may be examined in the offices of
the Texas Health and Human Services Commission or in the Texas Register office,
Room 245, James Earl Rudder Building, 1019 Brazos Street, Austin.)
The Health and Human Services Commission ("commission")
proposes the repeal of §354.3200, relating to Cost Sharing for Medicaid
Recipients. The repeal is proposed simultaneously with the proposed amendments
of §354.1875, relating to Limitations on Provider Charges to Recipients,
and §353.8551, relating to the Medicaid Vendor Drug Program Dispensing
Fee.
Section 354.3200 was adopted in late 2002, simultaneously with the adoption
of subsections (b) and (d) of §354.1875, and an amendment to §355.8551.
Subsection (b) authorizes the commission to reduce the amount of reimbursement
paid to a pharmacy provider enrolled in the Medicaid Vendor Drug Program by
any cost sharing amount required of a Medicaid recipient pursuant to §354.3200
of this title. Subsection (d) confirms a Medicaid recipient's responsibility
for cost sharing amounts in accordance with federal regulations that authorize
and limit recipient cost sharing. The amendment to §355.8551 modified
the amount of the dispensing fee and calculation of reimbursement paid to
pharmacy providers following the implementation of cost sharing under this
section.
The proposed amendment of §354.1875 scheduled to occur simultaneously
with the repeals of this section repeals subsections (b) and (d) of §354.1875.
The proposed amendment of §355.8551 scheduled to occur simultaneously
with the repeal of this section repeals a change in the calculation of the
dispensing fee paid under the Medicaid Vendor Drug Program.
The changes made by these rules were enjoined by a state district court
in Travis County on December 16, 2002, the first business day following the
effective date of the rules. The commission, therefore, has not implemented
the cost sharing established under §354.3200 or generated the program
cost savings that were anticipated from the successful implementation of the
section. The Texas Legislature also is currently considering legislation that
would codify certain Medicaid cost sharing requirements. The repeal of §354.3200
is proposed in order to accommodate new public policy as prescribed by the
78th Texas Legislature and to enable the commission to consider all potential
cost saving initiatives.
Tom Suehs, Deputy Commissioner for Financial Services, has determined that
for the first five years the proposed rule is in effect, there will be no
fiscal implications for the state or local governments as a result of the
repeal of the rule. Because the cost sharing requirements established under
this section were never implemented, the state has not realized the cost savings
anticipated from the adoption of this rule.
Mr. Suehs also has determined that during the first five years the proposed
repeal is in effect, no change in public benefit is anticipated as a result
of enforcing the amended rule. As the proposed repeal conforms to policy currently
in effect, there is no anticipated impact on small businesses and micro-businesses
to comply, as they will not be required to modify business practices. For
the same reasons, there are no anticipated economic costs to persons who would
be required to comply with the repealed rule. There is no anticipated impact
on local employment.
HHSC has determined that the proposed repeal does not constitute a "major
environmental rule" as defined by §2001.0225 of the Texas Government
Code. "Major environmental rule" is defined to mean a rule the specific intent
of which is to protect the environment or reduce risk to human health from
environmental exposure and that may adversely affect in a material way the
economy, a sector of the economy, productivity, competition, jobs, the environment
or the public health and safety of a state or a sector of the state. The proposed
repeal is not specifically intended to protect the environment or reduce risks
to human health from environmental exposure.
HHSC has determined that this proposed repeal does not restrict or limit
an owner's right to his or her property that would otherwise exist in the
absence of governmental action and therefore does not constitute a taking
under §2007.043, Government Code.
Written comments on the proposal may be submitted to Ms. Dee Sportsman,
Medicaid/CHIP Benefits, Texas Health and Human Services Commission, 1100 West
49th Street, Austin, Texas 78756, within 30 days of publication of this proposal
in the
Texas Register
.
The repeal is proposed under the Texas Government Code, §531.033,
which provides the Commissioner of HHSC with broad rulemaking authority; Human
Resources Code, §32.021, and the Texas Government Code, §531.021(a),
which provide HHSC with the authority to administer the federal medical assistance
program (Medicaid) in Texas; and the Texas Government Code, §531.021(b),
which provides HHSC with the authority to propose and adopt rules governing
the determination of Medicaid reimbursement rates, fees, and charges.
No other statutes, articles, or codes are affected by the proposal.
§354.3200.Cost sharing for Medicaid recipients.
This agency hereby certifies that the proposal has been
reviewed by legal counsel and found to be within the agency's legal authority
to adopt.
Filed with the Office of
the Secretary of State on May 12, 2003.
TRD-200302959
Steve Aragon
General Counsel
Texas Health and Human Services Commission
Earliest possible date of adoption: June 22, 2003
For further information, please call: (512) 424-6576
Subchapter J. PURCHASED HEALTH SERVICES
28.
PHARMACY SERVICES: REIMBURSEMENT
The Health and Human Services Commission (HHSC) proposes to repeal §355.8551,
concerning the calculation of the Medicaid Vendor Drug Program Dispensing
Fee and proposes new §355.8551. The proposed repeal and new language
modify the components of the dispensing fee, prescribe the estimated dispensing
expense and annual calculation of the expense, increase the inventory management
factor comprising part of the calculation, and authorize a delivery fee to
be added to provider reimbursement under certain conditions. The changes are
intended to reinstate program policy in effect before December 15, 2002, and
to accommodate current legislative consideration of potential program changes.
The current rule was promulgated simultaneously with the adoption in late
2002 of new Title 1, Chapter 354, §354.3200, relating to cost sharing
requirements for Medicaid recipients, and amendments to §354.1875 that
reduced pharmacy provider reimbursement by the amount of cost sharing collected
by a pharmacist. The changes made by these rules were enjoined by a state
district court in Travis County on December 16, 2002, the first business day
following the effective date of the rules. HHSC, therefore, has not implemented
the reimbursement changes established under the current language of this section
or generated the program cost savings that were anticipated from the successful
implementation of the changes to §354.1875 and §354.3200. The Texas
Legislature also is currently considering legislation that would codify certain
Medicaid cost sharing requirements. The amendment of this section is proposed
in order to accommodate new public policy as prescribed by the 78th Texas
Legislature relating to the Vendor Drug Program and to enable HHSC to consider
all potential cost saving initiatives.
The proposed rule reinstates the prior formula for calculation of dispensing
fee. The proposed rule also reinstates the flat dispensing fee or $5.27 beginning
state fiscal year 1997 and adjusted annually for inflation, such adjustment
subject to the availability of appropriated funds. The annual adjustment for
inflation must be based on a forecast of the Implicit Price Deflator-Personal
Consumption Expenditures produced by a nationally recognized forecasting firm
selected by the commission. The proposed rule also increases the inventory
management factor to 2% of the estimated drug ingredient cost and authorizes
payment of a delivery fee of no more than $.15 per prescription to providers
who deliver prescription drugs at no charge to Medicaid recipients who request
delivery.
Tom Suehs, Deputy Commissioner for Financial Services, has determined that
for the first five years the proposed repeal and new rule are in effect, there
will be no fiscal implications for the state or local governments as a result
of enforcing or administering the repeal or new rule.
Mr. Suehs also has determined that during the first five years the proposed
repeal and new rule are in effect, no change in public benefit is anticipated,
as a result of enforcing the repeal and new rule. There is no anticipated
impact on small businesses and micro-businesses to comply with the repeal
and new rule as proposed, as they will not be required to alter their business
practices. There are no anticipated economic costs to persons who are required
to comply with the proposed repeals and new rule. There is no anticipated
impact on local employment.
HHSC has determined that the proposed repeal and new rule are not a "major
environmental rule" as defined by §2001.0225 of the Texas Government
Code. "Major environmental rule" is defined to mean a rule the specific intent
of which is to protect the environment or reduce risk to human health from
environmental exposure and that may adversely affect in a material way the
economy, a sector of the economy, productivity, competition, jobs, the environment
or the public health and safety of a state or a sector of the state. The proposed
repeal and new rule are not specifically intended to protect the environment
or reduce risks to human health from environmental exposure.
HHSC has determined that this proposed repeal and new rule do not restrict
or limit an owner's right to their property that would otherwise exist in
the absence of governmental action and therefore do not constitute a taking
under §2007.043, Government Code.
Written comments on the proposal may be submitted to Ms. Pat Gladden, Medicaid/CHIP
Benefits, Texas Health and Human Services Commission, 1100 West 49th Street,
Austin, Texas 78756, within 30 days of publication of this proposal in the
§29.1
] of this title (relating to Claim Information Requirements),
the following information is required on claims for ambulance services:
provided, with justification, including flat rate charged
or number of miles traveled at a specified rate for air, ground, or boat ambulance
]; and
department
] or
its designee to support the determination of the medical necessity and appropriateness
of the ambulance transport. Examples of supporting documentation include,
but are not limited to, transferring records (medical; emergency room records
from transferring hospital); ambulance run sheets; time of transport; acuity
of client; distance of transport; traffic patterns; and actual distance to
nearest appropriate facility. [
Payments for services are determined on
a claim-by-claim basis using the documentation and information supplied by
the ambulance provider
].
Subchapter F. PHARMACY SERVICES
Health and Human Services Commission (HHSC) may reduce
the amount of the reimbursement paid to a pharmacy provider under this chapter
(relating to Medical Health Services) by any cost sharing amount required
of the Medicaid recipient, as described in §354.3200 of this title (relating
to Cost Sharing for Medicaid Recipients). The amount of the reduction may
not exceed 50% of the cost-sharing amount required of the Medicaid recipient,
as described in §354.3200 of this title (relating to Cost sharing for
Medicaid recipients).
]
(c)
]
The provider may neither charge nor take
other recourse against Medicaid recipients, their family members, or their
representatives for any claims denied or reduced by HHSC because of the provider's
failure to comply with any HHSC rule, regulation, or procedure.
(d)
In accordance with 42 C.F.R. §447.15,
an individual's inability to pay does not eliminate his or her liability for
the cost sharing charge.
]
Subchapter X. RECIPIENT COST SHARING
Chapter 355.
MEDICAID REIMBURSEMENT RATES